Manifestations of Gastrointestinal Disease in the Child

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Gastrointestinal Disease in the Child 697 TABLE 4. Age Intestinal transit time as a function of age Intestinal Transit Time (hours) 1 month 8 2 years 16 3-13 years 26 adult 48 Precipitants of constipation include: 1. Decreased fluid intake or increased fluid losses 2. Diet low in fibre 3. Chronic voluntary inhibition of defecation There are three periods when a child is particularly vulnerable to developing constipation: 1. The introduction of solid food in the diet of an infant 2. Toilet training 3. The start of school Any event such as an illness which might lead to prolonged fecal stasis in the colon with continued reabsorption of fluids will result in an increase in the size of the stool as well as drier consistency, which can cause painful defecation. The passage of large hard stools may then result in the child making efforts to withhold stool when they next experience an urge to defecate. Children will tighten their anal sphincter and contract their pelvic muscles in an attempt to withhold stool. They may be seen to stiffen their buttocks and legs, wriggle and grimace and often hide. Parents observing these contortions may not recognize that these are efforts to retain stool and believe that the child is straining in an attempt to defecate. The rectum will habituate to the presence of stool and the urge will subside. Over time the rectal wall stretches and becomes less sensitive. Furthermore, when the rectum is distended with a stool mass there is loss of the rectal-anorectal angle and the continence function of the puborectalis sling. Whenever there is a mass movement (HPAC) the only residual continence mechanism in these children is the external voluntary anal sphincter, which rapidly fatigues. This leads to involuntary soiling (encopresis). 3.3 Clinical Evaluation By far the majority of children with elimination problems have a functional defecation disorder. Some of the organic causes of constipation are listed in
698 FIRST PRINCIPLES OF GASTROENTEROLOGY TABLE 5. Organic causes of constipation in childhood Examples Anatomic malformations Central nervous system/ Neuroenteric disorders Metabolic/endocrine disorders Gastrointestinal disorders Drugs Systemic/genetic disorders Others Imperforate anus Anterior anus Strictures Hirschsprung’s disease Neurointestinal dysplasia Spinal cord abnormalities Neurofibromatosis Cerebral Palsy Hypotonia Hypothyroidism Hypercalcemia Hypokalemia Multiple Endocrine Neoplasia IIB Porphyria Cystic fibrosis Diabetes mellitus Diabetes insipidus Renal acidosis Celiac disease Cows’ milk allergy Opiates Anticholinergics Diuretics Iron Antidepressants Ehlers-Danlos, Scleroderma Lead intoxication Botulism Table 5. A thorough history and careful, focused physical examination is all that is usually necessary to make a diagnosis of a functional defecation disorder and exclude organic causes. There are a number of features of history and/or physical examination which would suggest the possibility of an organic cause for constipation (“red flags”) (Table 6). One of the most frequently considered organic problems in the differential diagnosis of infants presenting with constipation is Hirschsprung’s disease. This is a rare disease (approximately 1:5,000 live births), which is characterized by a lack of ganglion cells in the myenteric and sub mucous plexuses of the distal colon. This results in sustained contraction of this aganglionic segment.
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Manifestations of Gastrointestinal Disease in the Child

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